Effective as at 1st July 2020

Fund Rules WESTFUND HEALTH INSURANCE

Contents A INTRODUCTION ....................................................................................................................... 3

A1 Rules Arrangement .............................................................................................................................................. 3

A2 Health Benefits Fund ........................................................................................................................................... 3

A3 Obligations to Insurer ......................................................................................................................................... 3

A4 Governing Principles ........................................................................................................................................... 3

A5 Use of Funds ............................................................................................................................................................. 4

A6 No Improper Discrimination ................................................................................................................................ 4

A7 Changes to Rules ................................................................................................................................................... 4

A8 Dispute Resolution ............................................................................................................................................... 5

A9 Notices ....................................................................................................................................................................... 5

A10 Winding Up ........................................................................................................................................................... 6

A11 Other ........................................................................................................................................................................ 6

B INTERPRETATION AND DEFINITIONS ...................................................................................... 6 B1 Interpretation ......................................................................................................................................................... 6

B2 Definitions ................................................................................................................................................................ 6

B3 Other ........................................................................................................................................................................ 14

C MEMBERSHIP ........................................................................................................................ 14 C1 General Conditions of Membership ............................................................................................................ 14

C2 Eligibility for Membership .............................................................................................................................. 15

C3 Dependants ........................................................................................................................................................... 15

C4 Membership Applications ............................................................................................................................... 16

C5 Duration of Membership ................................................................................................................................. 17

C6 Transfers ................................................................................................................................................................ 17

C7 Cancellation of Membership .......................................................................................................................... 18

C8 Termination of Membership .......................................................................................................................... 18

C9 Temporary Suspension of Membership .................................................................................................... 19

C10 Other ..................................................................................................................................................................... 21

D CONTRIBUTIONS ................................................................................................................... 21 D1 Payment of Contributions .............................................................................................................................. 21

D2 Contribution Rate Changes ............................................................................................................................ 22

D3 Contribution Discounts ................................................................................................................................... 22

D4 Age-Based Discounts ........................................................................................................................................ 23

D5 Lifetime Health Cover ...................................................................................................................................... 24

D6 Arrears in Contributions ................................................................................................................................. 24

D7 Other ....................................................................................................................................................................... 24

E BENEFITS ............................................................................................................................... 25 E1 General Conditions ............................................................................................................................................ 25

E2 Hospital Treatment ........................................................................................................................................... 26

E3 General Treatment ............................................................................................................................................. 28

E4 Other ........................................................................................................................................................................ 34

F LIMITATION OF BENEFITS ...................................................................................................... 34 F1 Co Payments ......................................................................................................................................................... 34

F2 Excesses .................................................................................................................................................................. 35

F3 Waiting Periods ................................................................................................................................................... 35

F4 Exclusions .............................................................................................................................................................. 36

F5 Restricted Benefits ............................................................................................................................................. 36

F6 Compensation Damages and Provisional Payment of Claims .......................................................... 36

F7 Other ........................................................................................................................................................................ 37

G CLAIMS .................................................................................................................................. 37 G1 General ................................................................................................................................................................... 37

G2 Other ........................................................................................................................................................................ 42

A INTRODUCTION

A1 Rules Arrangement Words or expressions in Capital Bold are defined in Fund Rule B2 and are intended to be interpreted accordingly.

These rules consist of:

1. General Conditions (Fund Rules A-G)

A2 Health Benefits Fund A2.1 These are the rules of Westfund Ltd ABN 55 002 080 864 (Westfund), which trades as Westfund Health Insurance. These rules relate to the health benefits fund of Westfund that is registered under the PHIPS Act as a private health insurer. The Constitution of Westfund Ltd refers to these rules as “by-laws”.

A2.2 These rules govern the establishment and operation of the health benefits fund and describe the obligations, requirements and entitlements of Members of the Fund and the obligations, requirements and entitlements of Westfund in the operation of its health benefits fund.

A2.3 The health benefits fund relates solely to the health insurance business and health-related business of Westfund, as defined in the PHI Act.

A3 Obligations to Insurer A3.1 A person applying to be a Member shall:

comply with the requirements of Westfund; and

give full and complete disclosure on all matters required by Westfund.

A3.2 A Member shall inform Westfund as soon as reasonably possible after a change in any Policy details such as:

change of address;

change of contact details;

change of name;

change of marital status of a Dependant,

a Dependant ceasing to be a Dependant

A4 Governing Principles A4.1 These rules govern the operation of the Fund in conjunction with:

the Private Health Insurance Act 2007 and any Rules made under that act;

the Private Health Insurance (Prudential Supervision) Act 2015 and any Rules made under that act;

any conditions of registration imposed on Westfund, or any directions made by the Minister, under the PHI Act;

the Health Insurance Act 1973 and any regulations made under that act;

the circulars of the Australian Prudential Regulation Authority;

the circulars of the Department of Health;

Westfund’s Constitution;

A4.2 Where legal interpretation of the PHI Act or the PHIPS Act or the Health Insurance Act 1973 is in clear conflict with these rules these acts take precedence over these rules. Where no clear conflict is in existence then these rules take precedence.

A5 Use of Funds

A5.1 The following amounts must be credited to the Fund: a) Premiums payable under Policies of insurance that are referrable to the Fund; b) amounts paid to Westfund in relation to a liability under Part 3 Division 9 of the PHIPS Act

in relation to the Fund; c) income from the investment of assets of the Fund; d) money paid to or by Westfund under a judgement of a court relating to any matter

concerning the business of the Fund or any failure to comply with Part 3 of the PHIPS Act in relation to the Fund;

e) any other money received by Westfund in connection with its conduct of the business of the Fund; and

f) any other amounts specified in APRA rules made for the purpose of section 27(1) of the PHIPS Act.

A5.2 The assets of the Fund must not be applied for any purpose other than:

meeting Policy liabilities and other liabilities, or expenses, incurred for the purposes of the business of the Fund including Policy liabilities and other liabilities that are treated, in accordance with a restructure or arrangement approved under Division 4 of the PHIPS Act, as Policy liabilities and other liabilities incurred for the purposes of the Fund; or

making investments in accordance with s30 of the PHIPS Act; or

making a distribution under Part 3 Division 5 of the PHIPS Act; or

a purpose specified in the APRA rules for the purposes of section 28(2)(b) of the PHIPS Act.

A6 No Improper Discrimination

A6.1 When conducting the Fund and making decisions in relation to Members or persons seeking to become Members, subject to section 55.5 of the PHI Act, Westfund will not have regard to the following matters:

the suffering by a person from a chronic disease, illness or other medical condition or from a disease, illness or medical condition of a particular kind; or

the gender, race, sexual orientation or religious belief of a person; or

the age of a person, except to the extent allowed under Part 2-3 (lifetime health cover) or subsection 63-5(4) of the PHI Act (refer to D5);

where a person lives, except to the extent allowed under subsection 66-10(2) or section 66-20 of the PHI Act; or

any other characteristic of a person (including, but not just matters such as occupation or leisure pursuits) that is likely to result in an increased need for Hospital Treatment or General Treatment; or

the frequency with which a person needs Hospital Treatment or General Treatment; or

the amount or extent of the Benefits to which a person becomes entitled during a period under a Complying Health Insurance Policy, except to the extent allowed under section 66-15 of the PHI Act; or

any matter set out in the Private Health Insurance (Complying Product) Rules for the purposes of section 55-5(2)(h) of the PHI Act.

A7 Changes to Rules A7.1 The Fund may vary, delete or add to these rules at any time in accordance with the PHI Act with effect as set out in the relevant notice, whether or not Premiums have been paid in advance. Changes to rules apply to all Members immediately regardless of a Member’s paid to date.

A7.2 The Fund may waive at its discretion the application of particular rules provided that the waiver does not reduce the relevant Member’s entitlement to Benefits.

A7.3 The rules of the Fund that are in force at the date of the provision of a service for which a Fund Benefit under these rules is provided, are the rules which shall govern the provision of that Fund Benefit. If a Benefit is claimed for a service that occurred before the commencement of these rules and the Member was entitled to a Benefit under the previous rules then the Benefit payable shall be in accordance with the previous rules.

A7.4 The Fund will give a relevant Private Health Information Statement to the Primary Member at least once every 12 months.

A7.5 If a proposed change to the rules:

is or might be detrimental to a Member; and

will require an update to the Private Health Information Statement relevant to the Member,

then the Fund will ensure that the Primary Member:

is informed of the proposed change a reasonable time before the change takes effect, as required by section 93-20 of the PHI Act; and

is given the relevant updated Private Health Information Statement as soon as practicable after the statement is updated.

A7.6 If a proposed change to the rules is or might be detrimental to a Member and will not require an update to the Private Health Information Statement relevant to the Member, Westfund will ensure that the Primary Member is informed of the proposed change a reasonable time before the change takes effect.

A8 Dispute Resolution A8.1 A Member may make a complaint about any aspect of his or her Policy at any time.

A8.2 The Fund will endeavor to respond to the complaint as quickly and efficiently as possible.

A8.3 Disputes involving claims shall be referred to the Medical Adviser, Dental Expert or other appropriate expert appointed by Westfund. If, following receipt of the expert’s advice, Westfund rejects the claim, the expert’s advice to Westfund shall be made available to the Member concerned.

A8.4 The Commonwealth Ombudsman is available to assist Fund Members who have been unable to resolve disputes. However, the Member should give Westfund the opportunity to resolve the dispute before going to the Ombudsman.

A9 Notices A9.1 Rules requiring written notice in these rules such as changes in Premiums or detrimental changes in Fund Benefits will be communicated to the affected Primary Member, at the last address supplied to Westfund.

A9.2 Westfund may provide notice of changes (other than changes in Premiums or detrimental changes in Fund Benefits) or other information to a Primary Member by:

publication on Westfund’s internet web site; or

any electronic transmission; or

any other reasonable means.

A9.3 Copies of these rules are available to Members upon request.

A9.4 The Primary Member shall inform Westfund as soon as reasonably possible after a change in the Primary Member’s address.

A10 Winding Up A10.1 In the event of Westfund ceasing to be registered under the PHIPS Act, the Fund shall be

wound up in accordance with the requirements of the PHIPS Act.

A10.2 In the event of the winding up of the Fund all monies not required for meeting outstanding

liabilities, staff allowances, contracted payments and other expenses of winding up including the

requirements of the PHIPS Act, shall be utilised in such manner as may be required by the PHIPS Act.

A11 Other A11.1 Premiums paid in advance can be credited to another Policy should the Member Transfer to another Westfund Policy.

A11.2 Any specified entitlements accrued to a Member under a former Policy shall be deemed to accrue to the Member under a new Policy if the Member Transfers to a Policy that contains the specified entitlement that accrues.

A11.3 If a Member Transfers without interruption to a new Policy any limitation or qualifying period being met on the former Policy shall be applied towards meeting the same or similar limitation or qualifying period on the new Policy.

A11.4 Where Westfund has paid any moneys to a Member in error or the moneys were not lawfully due to the Member, Westfund is entitled to recover such moneys from the Member, including by way of offset against any future Benefit entitlements.

B INTERPRETATION AND DEFINITIONS

B1 Interpretation B1.1 These rules shall be interpreted so as not to conflict with Westfund’s Constitution;

B1.2 Where not defined, words and expressions are intended to have their ordinary meaning;

B1.3 The masculine gender shall include, where applicable, the feminine gender;

B1.4 Words in the singular number shall include the plural and words in the plural shall include the singular;

B1.5 Unless otherwise specified the definitions in the PHI Act (including Schedule 1 to the PHI Act), the PHIPS Act and the Health Insurance Act 1973 shall apply;

B1.6 In these rules, a reference to a statute or a provision in a statute shall be read as if the words “or any amendment or re-enactment thereof or provision substituted therefor” be added;

B1.7 In these rules, a reference to a Contract or a provision in a Contract shall be read as if the words “or any amendment thereof or provision substituted therefor” be added.

B2 Definitions In these rules unless the contrary intention appears:

Access Gap Scheme means the approved scheme conducted by the Australian Health Service Alliance providing above CMBS benefit payments where medical practitioners charge within agreed fee schedules and provide Informed Financial Consent to patients.

Accident means accidental bodily injury caused solely and directly by external means.

ADA Schedule means the Schedule of Dental Services published by the Australian Dental Association Incorporated.

Admitted Episode of Care means an admission to a Public or Private Hospital in order to receive the level of care that is only available as an inpatient. The patient must have undergone the admission process and then the discharge/separation process by the facility before it can be classed as an admitted episode of care.

Admitted Patient Care means an admitted patient as defined in the National Health Data Dictionary.

Adult means a person who is not a Dependant.

Advantage Extras means the Policy prescribed in Schedule I13.

Advantage Pro Extras means the Policy prescribed in Schedule I12.

Age-Based Discount means a discount on private health insurance for persons aged between 18 and

29 years.

Age-Based Discount Policy means an insurance Policy that provides Age-Based Discounts.

Ambulance means the Policy prescribed in Schedule I17.

Annual Group Limit means the maximum amount of Benefits that can be claimed for an individual service or group of services outlined within that group subject to Item Limits and Sub-limits that may apply. The Annual Group Limit is per Calendar Year.

APRA means the Australian Prudential Regulation Authority.

Athlete Core Extras means the Policy prescribed in Schedule I18.

Athlete Defend Extras means the Policy prescribed in Schedule I19.

Athlete Gold Hospital means the Policy prescribed in Schedule J58.

Athlete Guard Extras means the Policy prescribed in Schedule I20.

Athlete Protect Extras means the Policy prescribed in Schedule I22.

Athlete Shield Extras means the Policy prescribed in Schedule I23.

Athlete Silver Plus Hospital means the Policy prescribed in Schedule J59.

Athlete Silver Hospital means the Policy prescribed in Schedule J60.

Athlete Vital Extras means the Policy prescribed in Schedule I25.

Australia means the six States, the Northern Territory (NT), the Australian Capital Territory (ACT), Norfolk Island, the Territory of Cocos (Keeling) Islands and the Territory of Christmas Island.

Australian Resident has the same meaning as set out in the Health Insurance Act 1973.

Base Rate means the same as set out in section 34-1 of the PHI Act.

Basic Hospital means the Policy prescribed in Schedule J57.

Benefit means an amount of money payable or the provision of appliances under a Policy specified in these rules.

Board means the Board of Directors of Westfund.

Bronze Hospital means the Policy prescribed in Schedule J56.

Calendar Year means the twelve month period from 1 January to 31 December in a year.

Child means:

a natural child; or

an adopted child; or

a foster child: or

a stepchild (that is, a natural, adopted or foster child of the person’s Partner); or

a child being cared for under guardianship arrangements granted by a court of law.

Chronic Disease Management Program is a program approved by Westfund that is intended to

(a)reduce complications in a person with a diagnosed chronic disease; or

(b)prevent or delay the onset of chronic disease for a person with identified multiple risk

factors for chronic disease.

Claimable Period means a continuous period of time that can elapse for the maximum Item Limit to be exhausted. CMBS (Commonwealth Medicare Benefits Schedule) or MBS (Medicare Benefit Schedule) is a schedule of fees for Professional Services which attract Medicare Benefits maintained by the Department of Health.

Complying Health Insurance Policy is an insurance Policy that meets the following requirements of the PHI Act:

the community rating requirements in Division 66 of the PHI Act; and

the coverage requirements in Division 69 of the PHI Act; and

if the Policy covers Hospital Treatment – the benefit requirements in Division 72 of the PHI Act; and

the Waiting Period requirements in Division 75 of the PHI Act; and

the portability requirements in Division 78 of the PHI Act; and

the quality assurance requirements in Division 81 of the PHI Act; and

any requirements set out in the Private Health Insurance (Complying Product) Rules for the purposes of section 69-1 of the PHI Act.

Complying Health Insurance Product is a product made up of Complying Health Insurance Policies. A product is all Policies that cover the same treatments, and that provide Benefits that are worked out in the same way, and whose other terms and conditions are the same as each other.

Contract has the same meaning as Purchaser-Provider Agreement.

Contribution Group means a group of Members approved by Westfund for the purposes of Rule D1.2 and may include a group based on employment, membership of a professional association, time as a Policy holder or other basis which is permitted by the PHI Act.

Co-Payment means an amount payable by a Member for each day of Hospital Treatment or Hospital-Substitute Treatment. The Co-Payment is either paid by the Member or subtracted from any Benefit which would otherwise be payable.

Day Hospital Facility means a hospital as defined in the PHI Act to which a person is usually admitted for Hospital Treatment and discharged prior to midnight on the day of admission.

Default Benefit means, in the relation to Hospital Treatment, the minimum Benefit payable from a Hospital Policy as prescribed by the Minister from time to time.

Dental Expert means a registered dental practitioner appointed by Westfund to give technical advice on dental matters.

Dental Schedule means the Schedule referred to in Schedule M1 used to determine Benefits payable per item number. Dental Top Up means the additional dental Benefit that can be used for those Members on Overseas Top Plus Hospital with Extras, Ultimate Pro Extras, Ultimate Extras, Athlete Defend Extras, Athlete Protect Extras and Athlete Shield Extras Policies. The Dental Top Up can be used on any General Dental item (excluding 119, 141, 944, 949, 983, 984, 990 and 999) and Dentures up to 100% of the difference between the cost of the service and the dental Benefit paid.

Dependant means a Child aged under 25 years and who does not have a partner.

Devices for Sleep Apnoea and diagnosed snoring means CPAP Machines, EPAP Treatment, oral

appliances for diagnosed snoring , APAP Machines and BiPAP Machines.

Discount Assessment Date means whichever of the following is applicable in relation to a person who is insured under an Age-Based Discount Policy:

(a) subject to paragraph (c), if the Policy provided Age-Based Discounts as at the date the person became insured – that date; (b) if the Policy provided Age-Based Discounts at a date after the person became insured – the date the person was first eligible for an Age-Based Discount under the Policy; (c) if:

(i) the person transferred to the Policy (the new Policy) from another Age-Based Discount Policy (the old Policy); and

(ii) at the time of the Transfer, the new Policy was stated to be a Retained Age-Based Discount Policy; and

(iii) the person was not a Dependant under the old Policy; the person’s Discount Assessment Date under the old Policy.

Emergency Ambulance Transport is ambulance transportation of an unplanned and non-routine nature for the purpose of providing immediate medical attention to a person in the opinion of the treating medical officer. This can include;

transport to Hospital requiring treatment at an emergency department

transport to Hospital requiring admission

Essential Extras means the Policy prescribed in Schedule I15.

Essential Pro Extras means the Policy prescribed in Schedule I14.

Esteem Extras means the Policy prescribed in Schedule I16.

Excess means an amount payable by a Member for Hospital Treatment or Hospital-Substitute Treatment in a Calendar Year where the payment would normally attract the Benefit in accordance with the Policy. The Excess is either paid by the Member or subtracted from any Benefit which would otherwise be payable.

Exclusion means the Policy does not cover treatment for that condition.

Forced Retrenchment Suspension means the suspension of a Policy or Member as a result of the Primary Member or Spouse/Partner being unemployed due to retrenchment on the ground of redundancy.

Fund means the health benefits fund operated by Westfund as a private health insurer under the PHIPS Act.

General Dental means Diagnostic Services (items 011-091), Preventive, Prophylactic and Bleaching

Services (items 111-171), Extractions (items 311-324), Restorative Services (items 511-525, 531-535,

541-555, 571-579, 595-597), General Services (items 911-972) and Miscellaneous (items 981-999)

performed by a Recognised Provider.

General Treatment as set out in section 121-10 of the PHI Act.

General Treatment Policies are those outlined in Schedule I.

Gold means the Policy prescribed in Schedule J1.

Gold Classic means the Policy prescribed in Schedule J25.

Gold Hospital means the Policy prescribed in Schedule J52.

Health Management Program means a program approved by Westfund that is intended to ameliorate a specific health condition or conditions.

Hospital means a private hospital, a public hospital or a day hospital facility declared by the Minister pursuant to section 121-5(6) of the PHI Act.

Hospital Policy means a Policy provided to meet the cost of Hospital Treatment and associated Professional Services prescribed under Schedule J.

Hospital-Substitute Treatment as set out in section 69-10 of the PHI Act.

Hospital Treatment as set out in section 121-5 of the PHI Act.

Hospital Treatment Policies are those outlined in Schedule J.

Informed Financial Consent is the consent to treatment obtained by a doctor from a patient prior to treatment whenever possible, after the doctor has sufficiently explained his or her fees to the patient to enable the patient to make a fully informed decision about costs.

Insured Group means, for the purpose of paragraph 63-5(2A)(b) of the PHI Act, the following groups specified by reference to the number and kind of people in the group:

only one person

2 Adults (and no-one else)

2 or more people, none of whom is an Adult

2 or more people, only one of whom is an Adult

3 or more people, only 2 of whom are Adults

3 or more people, at least 3 of whom are Adults

Item Limit means the Benefit payable per service outlined in schedules I - J

Known Gap Cover means the Benefits which provide cover for Professional Services where the Member has been provided with Informed Financial Consent up to a specified percentage above the CMBS fee, or the cost of the service if less.

Lifetime Health Cover means the scheme set out in Part 2-3 of the PHI Act.

Lifetime Health Cover Age has the meaning given in section 34-1 of the PHI Act (that is – generally – the person’s age on the 1 July before the day on which the person took out Hospital cover). If the person took out Hospital cover before 1 July following their 31st birthday, the person would have a Lifetime Health Cover Age of 30.

Major Dental means Periodontics (items 213-251), Oral Surgery (items 331-399), Endodontics (items 411-458) and Prosthodontics: Crowns, Bridges, Veneers, Implants and Dentures (items 526, 536, 556, 586-588, 611-779) performed by a Recognised Provider.

MBS (Medicare Benefit Schedule) has the same meaning as CMBS (Commonwealth Medicare Benefit Schedule).

Medical Adviser means a qualified medical practitioner appointed by Westfund to give technical advice on professional matters, in particular in relation to Pre-existing Condition rulings.

Medical Gap is the difference, if any, between the cost of a Professional Service and the combined Medicare Benefit and Westfund Benefit.

Medically Necessary/Justified means where the treating doctor requests ambulance transport because the medical condition requires that level of support.

Medicare Benefit means a Medicare benefit under Part II of the Health Insurance Act 1973. The Medicare Benefit is 75% of the CMBS fee for in-hospital Professional Services.

Member means an insured person under a Policy.

MIMS means the Monthly Index of Medical Specialties, a subscription service providing medical practitioners and healthcare professionals with drug information.

Minister means the Federal Minister for Health or his or her delegate with the powers vested in the Minister by the PHI Act or the PHIPS Act.

Non-Emergency Patient Transport is ambulance transportation including on the spot treatment where a time critical ambulance response is not essential however clinical monitoring is required for the purpose of providing medical attention to a person in the opinion of the treating medical officer. Transport will be provided to a person where he or she is assessed by a medical practitioner as medically unsuitable for community, public or private transport. Non-Emergency Patient Transport must be requested from the treating medical practitioner and be provided under a state-based ambulance service scheme and recognised with Westfund. This may include services such as:

Ambulance service fees where subsequent transport is not required

Inter Hospital transfers (excluding public hospital to public hospital)

Admissions to Hospital from home

Nursing-Home Type Patient has the same meaning as in subsection 3(1) of the Health Insurance Act 1973.

Orthodontia means dental item numbers 811-881 performed by a Recognised Provider.

Overseas has the same meaning as set out in section 34-30 of the PHI Act.

Overseas Hospital means the Policy prescribed in Schedule L3.

Overseas Top Hospital with Extras means the Policy prescribed in Schedule L1.

Overseas Top Plus Hospital with Extras means the Policy prescribed in Schedule L2.

Partner means a person who:

is married to the Primary Member, or

lives with the Primary Member in a relationship on a bona fide domestic basis

PBS means the Commonwealth Government’s Pharmaceutical Benefits Scheme.

PBS Item means any drug listed in the Pharmaceutical Benefits Schedule.

Permitted Days Without Hospital Cover has the meaning given in section 34-20 of the PHI Act.

Pharmaceutical Benefits Schedule means the Schedule of Pharmaceutical Benefits kept by the Commonwealth Department of Health.

PHI Act means the Private Health Insurance Act 2007 (Cth).

PHIPS Act means the Private Health Insurance (Prudential Supervision) 2015 (Cth).

Policy means a Hospital Policy (specified in Schedule J) or a General Treatment Policy (specified in Schedule I) or a combined Hospital and General Treatment Policy (specified in Schedule J) that provides entitlement to Benefits payable in respect of approved expenses incurred by the Members of that Policy as specified in these rules.

Policy Year means a year from the date of commencement of a Policy or from the anniversary date of the commencement of a Policy.

Pre-existing Condition as set out in section 75-15 of the PHI Act means an ailment, illness or condition that, in the opinion of a medical practitioner appointed by Westfund, the signs or symptoms of that ailment, illness or condition existed at any time in the period of 6 months ending on the day on which the person became insured under the Policy. In forming the opinion, the medical practitioner must have regard to any information in relation to the ailment, illness or condition that the medical practitioner who treated the ailment, illness or condition gives him or her.

Premium means an amount of money a Member is required to pay for a specified period for a Policy.

Prescribed 35 Day Period means that the patient has been in a Hospital (or Hospitals) for 35 days without a break of 7 days or more during the last 12 months from the date of the first admission.

Primary Member means the person in whose name the Policy is registered with Westfund and who is a policy holder as defined in the PHI Act.

Private Health Information Statement for a Complying Health Insurance Product is a statement about the product that contains the information, and is in the form, set out in the Private Health Insurance (Complying Product) Rules.

Professional Service means a service provided by a medical practitioner to, or in respect of, an inpatient of a Hospital for which a Medicare Benefit is payable.

Protected Industrial Action means protected industrial action as defined in section 408 of the Fair Work Act 2009 (Cth) including lockouts as described in section 19 of the Fair Work Act 2009 (Cth), provided that such protected industrial action causes the Primary Member or Spouse/Partner’s income from the Primary Member’ or Spouse/Partner’s only or principal employer to cease for the period of that protected industrial action.

Purchaser-Provider Agreement means a Hospital Purchaser-Provider Agreement or a Medical Purchaser-Provider Agreement or a Practitioner Agreement which is an agreement between Westfund and a provider in respect of the provision of services to Members.

Recognised Provider means a provider recognised by Westfund for the purpose of paying Benefits. To become a Recognised Provider, the provider must be in Australia and among other things, satisfy the standards in the Private Health Insurance (Accreditation) Rules. Recognised Providers include Hospitals, medical practitioners providing a Professional Service and providers of General Treatment that meet Westfund’s Recognition Criteria.

Recognition Criteria in relation to Recognised Providers of General Treatment are:

the provider is professionally qualified or belongs to a professional body recognised by Westfund;

the provider is in independent private practice;

the provider is registered, or holds a licence under State or Territory legislation within Australia;

other recognition criteria determined by Westfund.

Respiratory Aids means Nebulisers, Peak Flow Meters, Spacer Devices and Mucus Clearing Devices.

Respite Care refers to the accommodation of a patient in a Hospital where the primary reason for the admission is to provide temporary relief from the home care of the patient to the person who is administering the home care, rather than to provide care for the patient. No Benefit is payable for Respite Care.

Restricted Benefit means a Benefit for a particular type of admitted Hospital Treatment, which covers the charges up to the public hospital, shared room accommodation rate, as set out by the Private Health Insurance (Benefit Requirement) Rules and determined by the Minister.

Retained Age-Based Discount means the Age-Based Discount that a Member held on a previous health insurance product. The Member will retain the same discount that they were eligible for on their previous product unless they do not fulfil the criteria for a Retained Age-Based Discount as set out in the Private health Insurance (Complying Product) Rules 2015.

Retained Age-Based Discount Policy means a Policy that is an Age-Based Discount Policy and that states it is a Retained Age-Based Discount Policy.

Silver Hospital means the Policy prescribed in Schedule J55.

Silver Plus Assure Hospital means the Policy prescribed in Schedule J53.

Silver Plus Nurture Hospital means the Policy prescribed in Schedule J54.

Spouse has the same meaning as Partner.

State of Residence means the State/Territory in which the Primary Member currently resides. For the purposes of these Fund rules:

A Primary Member living in the Australian Capital Territory (ACT) or Norfolk Island is taken to be a resident of New South Wales (NSW)

A Primary Member living in the Territory of Cocos (Keeling) Islands or the Territory of Christmas Island is taken to be a resident of the Northern Territory (NT).

Sub-limit means the maximum limit within the Annual Group Limit that the Item Limit can be claimed up to.

TGA Approved means an item that has been entered on the Australian Register of Therapeutic Goods.

Transfer has the meaning as set out in section 75-10 of the PHI Act.

Ultimate Extras means the Policy prescribed in Schedule I11.

Ultimate Pro Extras means the Policy prescribed in Schedule I10.

Usual Customary and Reasonable Charge means in relation to a service, the usual or customary fee charged for that service by other similarly qualified practitioners or a reasonable charge for that service as determined by Westfund having regard to the usual or customary charges for a similar service and/or advice from the practitioner’s professional association or body.

Vaccination means a preventive measure, in the form of injection or orally, taken to prevent a disease.

Waiting Period as set out in section 75-5 of the PHI Act means the period that applies to a person for a Benefit under a Policy being the period:

starting at the time the person becomes insured under the Policy; and

ending at the time specified in the Policy; during which the person is not entitled to the Benefit.

B3 Other

C MEMBERSHIP

C1 General Conditions of Membership C1.1 Members of the Fund shall have the right to obtain from Westfund, the Benefits and/or services

as provided under these rules.

C1.2 All Members under the same Policy shall belong to the same Insured Group, and have the same Policy.

C1.3 There are six types of Insured Group representing Policies Westfund may choose to offer from time to time:

a) only one person; referred to as a single Policy b) 2 Adults (and no-one else); referred to as a couple Policy c) 2 or more people, none of whom is an Adult; referred to as a Dependant only Policy d) 2 or more people, only one of whom is an Adult; referred to as a single parent Policy e) 3 or more people, only 2 of whom are Adults; referred to as a family Policy f) 3 or more people, at least 3 of whom are Adults; referred to as a family Policy

C1.4 A Member may contribute to any of the following Policies offered by Westfund in the Member's State of Residence:

any one Policy set out in Schedule J that provides Hospital Treatment

any one Policy set out in Schedule I that provides General Treatment but not including Hospital-Substitute Treatment

any combination of a Hospital Treatment Policy and General Treatment Policy (that may include Hospital-Substitute Treatment) set out in Schedules I and J

any one Policy set out in Schedule J that provides both Hospital Treatment and General Treatment (which may include Hospital-Substitute Treatment)

C2 Eligibility for Membership C2.1 Subject to these rules any person who is 18 years of age or more is entitled to apply in his or her own right as a Primary Member.

C2.2 Any person who applies for a Policy shall be known as the Primary Member. The Primary Member may also apply to cover his or her Partner or Dependants. A Primary Member may not receive Benefits in respect of any person other than the Primary Member unless that person is registered on the Policy as a Dependant. The Primary Member for a Dependant only Policy is only entitled to receive Benefits in respect of a person registered on the Policy as a Dependant.

C2.3 A person may not concurrently have a Policy that covers Hospital Treatment with the health benefits fund of another private health insurer and Westfund.

C2.4 Subject to Westfund’s discretion a person may not concurrently have a Policy that covers General Treatment with the health benefits fund of another private health insurer and Westfund.

C2.5 A person may be a Primary Member of both Westfund and another health benefits fund of another private health insurer, where a Hospital Treatment Policy is held with one private health insurer and a General Treatment Policy is held with the other private health insurer.

C3 Dependants C3.1 A Primary Member may register their Partner and/or Dependant on an appropriate Policy other than a Policy for an Insured Group of one.

C3.2 A newborn Child of a Member will be covered if they are added to an eligible Policy (refer rule C1.3) within three months of birth. In this case, continuity of cover applies to the newborn Child. The Child must be added prior to making a claim.

C3.3 Westfund, at its discretion, may allow a Primary Member to register as a Dependant, a person already registered as a Dependant on another Policy (even if with another health benefits fund), provided that the Primary Member is the parent or guardian.

C3.4 A person who ceases to be a Dependant (even if with another private health insurer) may join Westfund as a Primary Member without any additional Waiting Periods provided the new Policy does not provide a higher level of Benefits. Where the new Policy provides a higher level of Benefit, Waiting Periods will apply to the difference in Benefits.

C3.5 If a person was a Member (even if with the health benefits fund of another private health insurer) immediately prior to becoming a Dependant on a different Policy, the person’s Policy will be regarded as continuous.

C4 Membership Applications C4.1 A person may apply to be a Member of the Fund by:

a) Completing the specified application form, or b) Completing an application online and providing an online acknowledgement and

acceptance of the terms and conditions of membership, or c) Completing an application over the phone and providing a recorded acknowledgement and

acceptance of the terms and conditions of membership, and by providing any additional information relevant to the application requested by Westfund.

By making an application pursuant to paragraphs (a), (b) or (c) the applicant agrees that, in respect of any application or claim form signed by the applicant or another person covered under the relevant Policy and permitted by these rules, the signing of the form constitutes consent given by the signatory of the form (and if the form is not signed by the applicant, an undertaking by the applicant to procure such consent) in favour of the Hospital or other relevant authorities authorising them to supply any information to Westfund or its agent.

C4.2 The applicant must be the person who will be the Primary Member unless an application is being submitted by an agent approved by Westfund on behalf of the applicant.

C4.3 An applicant who intends to pay his or her Premiums by direct debit must accompany his or her application with a payment equivalent to at least:

One week in the case of weekly direct debit

One fortnight in the case of fortnightly direct debit

One month in the case of monthly direct debit

C4.4 Applicants who intend to pay their Premiums directly (over the counter/mail) or through a payroll group must provide at least one month’s Premium with their application.

C4.5 Westfund will not refuse any Policy application on the ground of any of the matters set out in Rule A6.1.

C4.6 If Westfund has exercised its rights to terminate a Policy, Westfund shall have the right to refuse an application for a Policy from a former Member who has been terminated.

C4.7 Where an application is refused, Westfund shall provide a reason for the refusal.

C4.8 The Partner of a Primary Member may deal with Westfund in respect of all other matters concerning the Policy except for the addition or subtraction of a Dependant and the change of Policy. The Primary Member may provide his or her Partner with these additional powers by granting spousal authority via written authorisation or by recorded acknowledgement over the telephone.

C4.9 Westfund may require proof of identity, age, and previous health cover at the time of an initial application for a Policy and at the time of any application to change the Policy or Dependants.

C4.10 Westfund will inform any person enquiring in relation to Complying Health Insurance Products about Private Health Information Statements and how to obtain a copy. Westfund will provide a copy of the relevant statement if the person so requests.

C4.11 Westfund will provide an up to date copy of the relevant Private Health Information Statement when an Adult first becomes insured. This statement will be provided to the Primary Member.

C5 Duration of Membership C5.1 Provided that the first Premium has been paid, the commencement date of a Policy shall be the later of:

the day the Policy application is accepted by Westfund; or

the date nominated by the applicant and accepted by Westfund;

except that in the case of transferring members, an earlier date may be agreed at the discretion of Westfund being a date up to 2 months prior to the date the application is received for the purposes of maintaining continuity of cover.

C5.2 A Policy will continue while Premiums continue to be paid until cancellation by the Primary Member, Partner with spousal authority or cancellation by Westfund due to failure of a Member to observe these rules.

C5.3 In respect of Policy Review Period (cooling off period), new Members and Members who have transferred to another Westfund Policy are entitled to a review period of 30 days from the date the Policy or the changed Policy commences.

Primary Members who decide during this review period that they do not want the Policy or want to change it in any way, will either be refunded their Premiums or transferred to a more appropriate Policy effective from the original date of application.

If a Primary Member chooses to change to a Policy with greater Benefits from the original date of application he or she will be required to pay any difference in Premiums from that date and will be subject to Waiting Periods associated with the higher level of cover.

The review period does not apply if a Member makes a claim in respect of the 30-day review period.

C6 Transfers C6.1 When a member of the health benefits fund of another private health insurer Transfers to Westfund without a break in coverage, Westfund may apply all relevant Waiting Periods:

to any Benefits under the Westfund Policy that were not provided under the previous policy;

to any difference between the Benefits that would have been provided under the previous policy and the Benefits payable by Westfund where the Westfund Policy Benefit is higher;

to the unexpired portions of any Waiting Periods not fully served under the previous policy;

to the difference between any Excess or Co-Payment payable under the previous policy and the new Policy (where the previous policy carried a higher Excess or Co-Payment).

C6.2 Where a Westfund Member Transfers to another Westfund Policy he or she shall be treated as a Transfer from the health benefits fund of another private health insurer in relation to the application of Waiting Periods.

C6.3 Where a Member Transfers from the health benefits fund of another private health insurer or to a different Westfund Policy, any Benefits that have been paid that were subject to an annual or other limits under the previous policy may be taken into account in determining the Benefits payable under the new Policy.

C6.4 Incremental Benefits or Benefit limits paid in relation to the policy held at the health benefits fund of the previous insurer or with Westfund may be taken into account when determining any incremental Benefit or Benefit limit where the increment requires an accrued term of a specific Policy.

C6.5 A Waiting Period will not apply to a Policy that covers a person who holds a gold card or was entitled to treatment under a gold card (as defined in the PHI Act) or to members of the Australian Defence Force or people in Antarctica who have health cover provided as part of their employment.

C6.6 Westfund will provide in the approved form and within the period set out in the Private Health Insurance (Complying Product) Rules a Transfer certificate where a person ceases to be insured with Westfund.

C6.7 Westfund will request in the approved form and within the period set out in the Private Health Insurance (Complying Product) Rules a Transfer certificate from a person’s previous insurer where this has not been provided within 7 days of the person becoming insured by Westfund.

C7 Cancellation of Membership C7.1 A Primary Member or a Partner with spousal authority may:

cancel the Policy;

remove Dependants from the Policy.

C7.2 Westfund will refund Premiums paid in advance when a Policy ceases only where required to do so by law or where specified in these rules. Westfund may at its discretion upon written request refund Premiums paid in advance from the date of receipt of that request and after allowing an appropriate administrative charge.

C7.3 A Dependant aged at least 16 years of age may leave the Policy. A Dependant under 16 years of age may leave the Policy with the agreement of the Primary Member. Westfund will notify a change of this nature in writing to the Primary Member and the Dependant.

C7.4 A request to cancel a Policy must be in writing or by recorded confirmation.

C7.5 The date of cessation of a Policy will be the later of the date requested by the Member or the date of receipt by Westfund of the relevant communication from the Member except that in the case of Transferring Members, an earlier date may be agreed at the discretion of Westfund being a date up to 2 months prior to the date the cancellation request is received for the purposes of avoiding overlap of cover.

C7.6 A Primary Member who has been given rate protection due to his or her Premiums being paid in advance and who cancels his or her Policy before the end of the period paid in advance will lose his or her rate protection.

C8 Termination of Membership C8.1 Westfund shall not have the right to terminate the Policy of any Member on the ground of any of the matters set out in Rule A6.1.

C8.2 Westfund shall have the right to terminate the Policy of a Member from the date of notification to that Member, if any Member in that Policy has, in the opinion of Westfund, committed or attempted to commit fraud upon Westfund. Any Premiums paid in advance of the date of cancellation of the Policy may be first applied by Westfund to offset the cost of the fraud or attempted fraud, with Westfund being only liable to the Member of the cancelled Policy for any balance remaining.

C8.3 Westfund shall have the right to terminate the Policy of a Member if the application for the Policy for that Member contained inaccurate or incomplete information in a material respect and such right may be effected from the date such Policy commenced. “Material” means that Westfund could have made a different decision if provided with accurate and/or complete information.

C8.4 Westfund shall have the right to terminate a Policy if any Member with a Hospital Treatment Policy concurrently has a Hospital Treatment Policy with the health benefits fund of another private health insurer.

C8.5 Westfund may terminate a Policy in circumstances other than those specified at C8.2, C8.3 or C8.4. In these circumstances Westfund will communicate with the Primary Member advising of the reason for the termination and provide the Primary Member with at least one month’s notice of the date of the termination.

C8.6 Westfund will refund any Premiums paid in advance as at the date of the termination but may deduct an appropriate amount from the refund for administrative expenses associated with processing the termination and any amounts wrongfully paid to or on behalf of the Member.

C8.7 Where Premiums are more than two months in arrears the Policy is terminated except at the discretion of Westfund. The Member remains liable for unpaid Premiums.

C8.8 Where a Policy has been terminated for non-payment of Premiums, the Member must complete a new application. Westfund may at its discretion and subject to payment of the Premium arrears, agree to waive Waiting Periods and reinstate any accumulated Benefit entitlements.

C8.9 Westfund will notify the Primary Member in writing where the Policy has been or will be terminated.

C8.10 A Member can be terminated from a Policy due to death under the following circumstances:

If the termination is requested by an existing Spouse on the same Policy that has been granted spousal authority

If the termination is requested by a person with power of attorney (power of attorney documentation to be supplied)

If a Death Certificate is supplied In the event that any of the above circumstances cannot be met, Westfund may terminate a

Member from a Policy due to death after receiving appropriate documentation as determined by Westfund

C9 Temporary Suspension of Membership C9.1.1 Westfund may allow suspension of a Policy or Member on grounds other than those listed in C9.2, C9.3, C9.4 for periods as it, in its absolute discretion, allows. C9.1.2 Any Policy (excluding Ambulance, Overseas Top Plus with Extras, Overseas Top Hospital with Extras and Overseas Hospital) is eligible for suspension. C9.1.3 A Member listed on an eligible Policy is eligible for suspension. C9.1.4 Health services provided during a suspension of a Policy or Member shall not be eligible for Benefits. C9.1.5 A suspension of a Policy or Member shall not qualify for the purpose of completing any Waiting Periods or Claimable Periods that are to be served by a Member before the Member is eligible to receive Benefits. C9.1.6 A minimum of six months must elapse from the end of the previous suspension period for the same suspension reason.

C9.1.7 Continuity of the Policy for the purposes of Lifetime Health Cover is subject to the provisions of section D5 of these rules. C9.1.8 Westfund may suspend a Policy or Member upon application by the Primary Member or Spouse/Partner with spousal authority. C9.1.9 If any criteria set out in C9.2, C9.3 or C9.4 in addition to C9.1 are not met, Westfund will terminate the Policy or Member. Westfund at its discretion may allow reinstatement of the Policy or Member if all abovementioned criteria are met. C9.2 Overseas Suspension C9.2.1 Suspension of a Policy or Member may be granted by Westfund if the reason for the suspension is the temporary absence from Australia for more than two months and no more than 24 months provided that Premiums are paid from the date of return to Australia. C9.2.2 A Policy will not be suspended unless paid to the suspension commencement date. C9.2.3 Proof of departure such as a boarding pass, itinerary or airline ticket must accompany the Overseas Travel Suspension Form prior to leaving Australia. C9.2.4 If a Policy or Member is leaving Australia within 6 months of a previous suspension period, proof of departure and the Overseas Travel Suspension Form must be supplied prior to leaving Australia; however the suspension commencement date must be 6 months from the end of the previous suspension period. C9.2.5 A Policy or Member must be reinstated from the date of return to Australia. Reinstatement must be within one month of returning to Australia and proof of entry such as a boarding pass, itinerary or airline ticket must be supplied. C9.3 Forced Retrenchment Suspension

C9.3.1 Westfund may suspend a Policy or Member (excluding a Dependant) who has had 3

continuous years of membership at the date of application for the Forced Retrenchment

Suspension.

C9.3.2 Suspension of a Policy or Member may be granted by Westfund only if the following

conditions have been met by the Member who has applied for the Forced Retrenchment

Suspension:

The Member is currently unemployed and has been unemployed for more than seven (7)

consecutive days

The Member’s unemployment was a result of forced retrenchment and not caused by a

voluntary act

The Spouse/Partner of the Member, who has applied for the Forced Retrenchment

Suspension, earns no more than the National Minimum Wage (Fair Work Commission) plus 30%

per week

The Member’s employment, at the time of retrenchment, was within Australia

Where the Member was self-employed, then the business must have been either legally

declared bankrupt or have been placed into involuntary liquidation

Where the Member’s engagement was entered into on a “contractor” type arrangement,

the forced retrenchment was not a result of a contract expiring. If the contractor is forced

into retrenchment during the period of the contract and he or she satisfies all other criteria in

C9.3 then he or she may be eligible for the suspension.

C9.3.3 The initial application for suspension due to forced retrenchment must be made within 3

months of the last day of paid employment.

C9.3.4 The Forced Retrenchment Suspension is applied from the date as declared on the Forced

Retrenchment Suspension Form and is valid for one (1) calendar month or until such time that the

criteria set out in C9.3.2 are no longer met, up to a maximum of six (6) consecutive calendar months.

C9.4 Protected Industrial Action Suspension

C9.4.1 Westfund may suspend a Policy or Member (excluding a Dependant) who has had 3

continuous years of membership at the date of application for the Protected Industrial Action

suspension.

C9.4.2 Suspension of a Policy or Member may be granted by Westfund only if the following

conditions have been met by the Member who has applied for the Protected Industrial Action

suspension:

The Member’s union has been taking Protected Industrial Action for more than seven (7) consecutive days

The Member’s engagement, at time of Protected Industrial Action, was within Australia

The Spouse/Partner of the Member, who has applied for the Protected Industrial Action suspension, earns no more than the National Minimum Wage (Fair Work Commission) plus 30% per week

Where the Member’s engagement was entered into on a “contractor” type arrangement, Protected Industrial Action was not a result of a contract expiring. If the contractor is forced into Protected Industrial Action during the period of the contract and he or she satisfies all other criteria in C9.4 the he or she may be eligible for the suspension. C9.4.3 The initial application for suspension due to Protected Industrial Action must be made within 3 months of the last day of paid work. C9.4.4 A Protected Industrial Action suspension may be granted provided the Protected Industrial Action Suspension Form is supported by written confirmation from the Member’s union that the Member is unable to work due to Protected Industrial Action. The written confirmation is effective for the period of Protected Industrial Action or one (1) week from the date of the written confirmation, whichever is longer. The written confirmation may be renewed, and the suspension may be extended for successive periods of one (1) week to a maximum of six (6) consecutive calendar months.

C10 Other

D CONTRIBUTIONS

D1 Payment of Contributions D1.1 Premiums payable for each Policy are set out in Schedule K – the Schedule of Premiums.

D1.2 Westfund may, at its discretion, approve any group of Members as a Contribution Group.

D1.3 A Member must pay Premiums at the rate for the chosen Insured Group and Policy. Premiums may be paid by a Member or on behalf of a Member by an agent approved by Westfund.

D1.4 Any Premiums paid by a Recognised Provider on behalf of a Member other than the Provider's Spouse, Partner or Dependant shall be returned to that provider if the Member attempts to claim Benefits for services rendered by the provider. The Member’s Premium status will be adjusted accordingly.

D1.5 All Premiums must be paid in advance, but a Policy cannot be more than 18 months Premiums in advance in total.

D1.6 An amount received as a Premium for a particular Policy shall be applied first in payment of any arrears of Premiums and then applied in respect of future periods.

D1.7 Premiums may vary between States. A Member will be required to pay the Premium for the State in which he or she resides as advised to Westfund. If a Member changes his or her State of Residence, the Premium for that new State or Territory will apply from the date of the change of residence.

D1.8 Any refund of Premiums received will be limited to the period of 2 years prior to the date of the receipt by Westfund of written notification of the circumstances which would render a Member or Dependant ineligible to receive Benefits. This circumstance may arise for example where a Member concurrently held equivalent Policies with two private health insurers. A Member would be ineligible for a refund if a Benefit has been paid under the Policy.

D2 Contribution Rate Changes D2.1 Westfund has the right to change Premiums in accordance with the requirements of the PHI Act.

D2.2 Westfund will advise the Primary Member in writing of the new Premiums before they take effect in accordance with the requirements of the PHI Act.

D2.3 In respect of changed Premiums, where a Member’s Premiums are paid in advance, Westfund will apply the new Premiums from the date to which those Premiums are paid in advance.

D2.4 A Member who has been given rate protection due to his or her Premiums being paid in advance and who cancels his or her Policy before the end of the period paid in advance will lose his or her rate protection and his or her Policy period will be adjusted accordingly.

D3 Contribution Discounts D3.1 The only discounts provided will be those permitted as set out in section 66-5 of the PHI Act. The maximum percentage discount allowed is 12% per annum.

D3.2 The discount for a Policy is the difference between the full Premium and the net Premium. The full Premium for a Policy is the Premium without any reductions due to circumstances as set out in section 66-5 of the PHI Act.

D3.3 The following costs are excluded from the calculation of net Premium: a) a brokerage fee or commission paid in respect of the Policy; and b) the cost of any discount, product, service, waiver or other thing (promotion) offered to a

person at the time the person first purchases a Policy from Westfund if: (i) the cost of the promotion does not exceed 12% of the full Premium, for a year, for the

Policy purchased; and (ii) the promotion is provided in the first year after the person purchases the Policy.

D3.4 Westfund may offer to all eligible Members in a Contribution Group a discount which: (i) is also available for that reason under every Policy in the product; (ii) is determined at the same time as Westfund’s Premium changes are determined; (iii) subject to (i) above, is offered on such conditions as are determined by Westfund; (iv) is certified by Westfund’s Appointed Actuary as being prudent and equitable; (v) applies from the date and for the period specified by Westfund. (vi) specified by Westfund.

D4 Age-Based Discounts D4.1 The Fund may operate the Age-Based Discount arrangement as set out in section 63-10 (g) of the

PHI Act. An insurance Policy must not provide an Age-Based Discount unless;

(a) the Policy covers:

(i) Hospital Treatment; or

(ii) Hospital Treatment and General Treatment; and

(b) the discount will be a reduction in the amount that would otherwise be payable by the person for

the Policy, equal to the dollar amount calculated in accordance with the PHI Act; and

(c) the discount will apply to each person insured under the Policy who, on the Discount Assessment

Date for the person:

(i) was within one or more ranges of ages, between 18 and 29 (inclusive), that are specified in the

Policy as eligible for the discount; and

(ii) was not a Dependant under the Policy; and

(d) while Age-Based Discounts are available under the Policy, the discount will continue to apply until

it is reduced to zero in relation to each such person insured under the Policy; and

(e) the Policy states whether it is a Retained Age-Based Discount Policy.

D4.2 A person’s base percentage is calculated using the formula as set out in the PHI Act and

corresponds to the person’s age at the Discount Assessment Date:

Person’s age at Discount Assessment Date Percentage

18 or older, but under 26 10%

26 8%

27 6%

28 4%

29 2%

D4.3 Once an eligible person turns 41 years of age; the Age-Based Discount will be removed

incrementally as set out in the PHI Act; as per the below table:

If, for that period, the person is aged: the person’s percentage for the period is:

18 or older, but under 41 the person’s base percentage

41 the person’s base percentage minus 2 percentage points

42 the person’s base percentage minus 4 percentage points

43 the person’s base percentage minus 6 percentage points

44 the person’s base percentage minus 8 percentage points

45 or older zero

D5 Lifetime Health Cover D5.1 The Fund shall operate the Lifetime Health Cover (LHC) arrangements in accordance with the PHI Act. Without limiting the foregoing:

The Fund is required to charge different Premiums for Hospital Policies depending on the age at which a person first takes out a Policy which covers Hospital Treatment and the continuity of such coverage;

A person who joins a health fund earlier in life and maintains a Policy which covers Hospital Treatment pays a lower Premium than someone who joins later in life due to Lifetime Health Cover loading;

From 1 July 2000, Premiums for people taking out a Hospital Policy after turning 30 years of age must include a loading of 2 per cent on the Base Rate Premium for the person’s Hospital Policy each year his or her Lifetime Health Cover Age exceeds 30 years. The maximum loading is 70 per cent of the Base Rate Premium for the Member’s Hospital Policy;

Where a Hospital Policy covers more than one Adult, the amount of any increase in the Premium due to the application of Lifetime Health Cover loading is calculated using the averaging method in section 37-20 of the PHI Act;

Premium increases stop after 10 years continuous cover (not counting any Permitted Days Without Hospital Cover), but may start again if the Member ceases to have a Policy which covers Hospital Treatment as specified in the PHI Act. Lifetime Health Cover recognises continuous cover even if the Member has had a Policy which covers Hospital Treatment from more than one health fund;

Continuity for the purposes of Lifetime Health Cover is preserved during a period in which the Member ceases to have a Policy which covers Hospital Treatment for a cumulative period of 1,094 days or otherwise in accordance with the PHI Act (known as Permitted Days Without Hospital Cover). However, after exceeding 1,094 Permitted Days Without Hospital Cover, a person must pay an additional loading of 2% of the Base Rate Premium for every year without Hospital cover (excluding Permitted Days Without Hospital Cover) on top of any previous loading. If a person takes out a Hospital Policy again after exceeding 1,094 Permitted Days Without Hospital Cover, the person must re-serve 10 years of continuous Hospital cover before Premiums stop increasing.

People born on or before 1 July 1934 are not affected by Lifetime Health Cover. If people in this age group take out a Hospital Policy at any time in the future they will pay the Base Rate Premium, with no loading for late entry.

D6 Arrears in Contributions D6.1 If a Member has not made a Premium payment prior to the ‘paid to’ date, then that Member shall be regarded as being in arrears.

D6.2 If a Member is less than two months in arrears, the Member may pay all Premiums in respect of the period in arrears and the Member will then be eligible for Benefits in respect of that period.

D6.3 When a Member is more than two months Premiums in arrears then his or her Policy shall be terminated from the last ‘paid to’ date of the Policy except at the discretion of Westfund.

D6.4 No Benefits shall be paid for services rendered to a Member during the period in which his Policy is in arrears until the arrears in Premiums are paid.

D7 Other D7.1 Some Policies provide for waiver of Premiums for Financial Hardship. Where this is provided in a Policy, the circumstances, terms and conditions are as follows.

D7.2 Hardship Provision

D7.2.1 Westfund may allow upon application by the Primary Member or Spouse/Partner who is covered by the same Westfund Policy, who has had 3 continuous years of membership at the date of application for the Hardship Provision. Payment of Premiums may be delayed by up to 6 months under this Hardship Provision where application has been received by Westfund within two (2) months of the Policy’s “paid to” date being in arrears.

D7.2.2 If a Policy is in arrears on a Hospital (Schedule J) or combined Hospital and General Treatment Policy (Schedule J) because of being temporarily unable to work due to illness or other incapacity, strikes, lockouts or any other hardship provision agreed to by Westfund and provided that the Member undertakes in writing that, after he or she resumes work, Premiums will be paid weekly, at double the weekly rate, until such arrears are repaid, then notwithstanding other rules to the contrary, and at the discretion of Westfund, Benefits for any Member on the Policy shall continue to be paid while the Policy is in arrears, but for not more than six (6) months after the “paid to” date. Payment of Benefits is conditional on the Member, who has applied for the Hardship Provision, having furnished such evidence as Westfund requires as to his or her good faith in the making to the undertaking.

E BENEFITS

E1 General Conditions E1.1 Westfund offers health Benefit entitlements to its Members in accordance with the chosen Policy and the rules in force and the Benefits payable at the date on which the service was provided, subject to any applicable limits.

E1.2 Benefits are only payable for: a) Hospital Treatment, and/or b) General Treatment.

E1.3 Westfund may request any medical or other evidence, which it considers necessary to determine eligibility for Benefits.

E1.4 Benefits are only payable where services or appliances are provided by a Recognised Provider.

E1.5 Westfund has no liability to a Member for negligence, losses, costs, damages, suits or actions arising through the provision of services to any Member by any Recognised Provider.

E1.6 The following conditions apply to all Benefits:

Benefits are only payable for services rendered by providers who are recognised by Westfund and in private practice (Recognised Provider); as per the Private Health Insurance (Accreditation) Rules. Recognition by Westfund is for Benefit payment purposes only and is not to be construed as any recommendation of the qualifications and services provided by a provider;

Benefits shall not be payable for services which occurred earlier than 24 months before the lodgement of a valid claim;

Benefits must not exceed 100% of the documented cost to the Member of any service or item for which Benefits are payable;

Where moneys are payable from more than one source for a service, Westfund may limit the Benefit so that the amount payable from all sources does not exceed the amount charged;

Benefits are not payable in respect of services or treatment performed by a Recognised Provider to a Member where Premiums in respect of that Member have been given by that Recognised Provider;

General Treatment Benefits are not payable for services or treatment performed or recommended by a Recognised Provider to the provider's business partner, or to the Spouse, Partner or Dependants of the provider;

Benefits are not payable in respect of Dependants of Dependants registered on a Policy.

E1.7 Westfund may, in lieu of Benefits, provide services or appliances to a Member or Dependants.

E1.8 Where Benefits are determined as a percentage of the receipted cost of a service and the receipted cost of a service appears excessive, Westfund has the right to determine the Benefit from the Usual, Customary and Reasonable Charge it determines for that service.

E1.9 In the event that a Benefit has been erroneously paid (claim was not properly payable under these rules) then Westfund shall be entitled to recover any such amount or deduct the amount from any other Benefits payable in respect of the Policy or any Premiums paid in advance.

E1.10 Notwithstanding these rules, Westfund shall have the right to relax any particular term or condition in specific instances and Westfund shall also have the right to provide, without prejudice, an ex gratia payment.

E1.11 Benefits are only payable for treatments, health care goods and services provided in Australia.

E1.12 Waiting Periods are as detailed in Part F3 of these rules.

E1.13 Other conditions relating to Benefits, Limitation of Benefits and Claims are detailed in Parts E, F and G of these rules.

E2 Hospital Treatment E2.1 Hospital Benefits are payable in relation to the cost of Hospital Treatment.

E2.2 Hospital Treatment Benefits provided in Policies set out in Schedules J and L excludes:

treatment which involves a procedure that has an item number that is specified in clause 8 of Schedule 3 of the Private Health Insurance (Benefit Requirements) Rules, if no certificate for that procedure has been provided under clause 7 of that Schedule;

treatment provided to a person at an emergency department of a Hospital;

treatment provided to a person who is not a patient within the meaning of that word in paragraph (b) of the definition of ‘patient’ in subsection 3(1) of the Health Insurance Act 1973 (‘patient’ does not include a newly born child whose mother also occupies a bed in the Hospital except in certain specified circumstances);

treatment which is part of a chronic disease management program that is intended to delay the onset of chronic disease for a person with identified multiple risk factors for chronic disease;

the cost of care and accommodation in an aged care service (within the meaning of the Aged Care Act 1997);

a charge for a pharmaceutical benefit supplied under Part VII of the National Health Act 1953, unless the circumstances of the charge are covered by section 92B of that Act;

any other treatment specified in the Private Health Insurance (Complying Product) Rules as a treatment for which Benefits must not be provided.

E2.3 Westfund will pay Benefits for Hospital Treatment at least equivalent to the following:

The amount detailed in the Private Health Insurance (Complying Product) Rules as the minimum Benefit for Hospital Treatment that is psychiatric, rehabilitation, and palliative care if the treatment is provided in a Hospital and no Medicare Benefit is payable for that part of the treatment

Up to 25% of the CMBS Fee for Hospital Treatment covered under the Policy for which a Medicare Benefit is payable

The amount detailed in the Private Health Insurance (Prostheses) Rules as the minimum Benefit for a prostheses where a prostheses is provided in circumstances in which a Medicare Benefit is payable

E2.4 Westfund may enter a Contract with a Hospital or a group of Hospitals for Hospital Treatment. Contracts specify the total charge for any Hospital Treatment and the Benefit payable. The Member’s entitlement to a Benefit in a contracted Hospital is determined in accordance with the terms of the Contract and the Policy. A list of contracted Hospitals is available to Members on our website: www.westfund.com.au.

E2.5 Benefits for Hospital Treatment provided in a private Hospital which does not have a Contract with Westfund are payable at the minimum and second tier default rates as applicable, determined under the Private Health Insurance (Benefit Requirements) Rules.

E2.6 Westfund will also pay on some Hospital Treatment Policies, all or part of the fee that is above the CMBS fee in cases where the medical practitioner either has a Contract with Westfund or participates in Westfund’s Access Gap Scheme arrangements.

E2.7 For the purposes of determining the level of Benefit paid for Hospital Treatment, unless otherwise specified, where a Member is readmitted, the Hospital Treatment is regarded as a continuation of the preceding admission where there is a related reason for the readmission.

E2.8 In determining the Benefit payable where a daily Benefit is paid for services provided by the Hospital, the day of discharge and the day of admission are counted as one day.

E2.9 Where a patient is designated a Nursing-Home Type Patient, Benefits shall be limited to the current amounts determined by the Minister.

E2.10 Physiotherapy is covered in some Contracts with Hospitals. In Contracts where physiotherapy is not covered, Westfund will pay a Benefit in accordance with the specific product rules.

E2.11 For Medical Treatment in Hospital, Medicare pays a Benefit of 75% of the CMBS fee for Professional Services.

E2.12 For Medical Treatment in Hospital, Westfund will pay a Benefit of 25% of the CMBS fee for Professional Services.

E2.13 Where the charge for the Professional Service is less than the CMBS fee, the Benefit is the amount by which the charge exceeds 75% of that CMBS fee.

E2.14 Westfund shall have the right to dispute any claim for Benefits in respect of Professional Services or Hospital Treatment. In the event Westfund disputes a claim for Professional Services or Hospital Treatment, the Fund may at its absolute discretion refer the claim to its Medical Adviser. The Medical Adviser’s fees shall be paid by the Fund. If, following the advice of the Medical Adviser, Westfund decides not to pay the Benefits, this advice shall also be made available to the Member.

E2.15 Accommodation Benefit

E2.15.1 An Accommodation Benefit is payable for costs incurred as the result of boarding at a Hospital or nearby motel by the patient or one Member covered by the same Westfund Policy. Benefits are paid for the night before admission, for the nights during the hospitalisation and the night of discharge; where there is a corresponding hospitalisation record on the Members Policy. This Benefit is not claimable for the patient while admitted.

E2.15.2 The Accommodation Benefit is an uncapped Benefit payable per Policy per Calendar Year. A higher Benefit is payable for the first four nights claimed per Policy. All subsequent nights claimed will be paid at a lower nightly rate per Policy.

E2.15.3 To be eligible for the Accommodation Benefit the Member must be admitted as a private patient.

E2.16 Inpatient Travel Benefit

E2.16.1 An Inpatient Travel Benefit is payable for travel expenses incurred by a Member when receiving inpatient medical specialist services, where there is a corresponding hospitalisation record on the Members Policy.

E2.16.2 Benefits will be paid on a grouped kilometre basis, in excess of 150 kilometres round trip from the Member’s home locality to the locality of the hospitalisation. This benefit is not available if transport is provided by Ambulance or Non-Emergency Patient Transport.

E2.16.3 This Benefit is limited to one service per Member per episode of hospitalisation.

E2.16.4 To be eligible for the Inpatient Travel Benefit the Member must be admitted as a private patient.

E2.16.5 The following limits apply to Benefits for inpatient travel expenses:

Distance Travelled Benefit

0-149km Nil

150km-200km $20

201km-250km $25

251km-300km $30

301km-350km $40

351km-400km $50

401km-450km $60

451km+ $70

E3 General Treatment E3.1 The Benefits payable in respect of General Treatment, and the conditions relevant to those Benefits, are set out in Schedules I, J and L.

E3.2 General Treatment provided in Policies set out in Schedules I, J and L excludes:

1. Services for which a Medicare Benefit is payable except: a) The professional medical therapeutic services identified in Groups T1 to T11 of

the Health Insurance (General Medical Services Table) Regulation that are:

items in the table without the symbol (H); or

not stated in the item to be services that are to be performed in a Hospital for the Medicare Benefit to be payable; and

b) oral and maxillofacial services set out in Groups O1 to O11 of the Health Insurance (General Medical Services Table) Regulation that are:

items in the table without the symbol (H); or

not stated in the item to be services that are to be performed in a Hospital for the Medicare Benefit to be payable; and

c) the associated services in the:

Department of Health - Pathology Services Table (PST); and

Health Insurance (Diagnostic Imaging Services Table) Regulation, that are integral to the provision of the services specified in paragraphs (a) and (b)

but only when any of the services in the above classes are provided as part of Hospital-Substitute Treatment.

2. Treatment which primarily takes the form of sport, recreation or entertainment, other than such treatment which is part of a chronic disease management program or a Health Management Program where the program has been approved by Westfund.

3. Benefits paid in connection with the birth of a baby, funeral benefits, and disability Benefits, other than where Members were entitled to these Benefits as at the commencement of the PHI Act, i.e. funeral benefit prior to 1 April 2007.

E3.3 Some Policies may incorporate Hospital-Substitute Treatment. For these Policies, Westfund will pay:

Up to 25% of the CMBS Fee for Hospital-Substitute Treatment covered under the Policy for which a Medicare Benefit is payable, provided a Medicare Benefit of 85% or more of the CMBS fee is not payable for the treatment (in which case no Benefit is payable)

No more than the amount (if any) set out in the Private Health Insurance (Prostheses) Rules as the maximum benefit for a prosthesis where the prosthesis is provided in circumstances in which a Medicare Benefit is payable

The amount set out in the Private Health Insurance (Complying Product) Rules as the minimum benefit for any treatment mandated for Benefits to be provided in those Rules.

E3.4 Westfund may make Chronic Disease Management Programs and other Health Management Programs available to Members under one or more Policies from time to time. Benefits payable in respect of Chronic Disease Management and other Health Management Programs are subject to the Member meeting any applicable enrolment or eligibility criteria specified by Westfund from time to time.

E3.5 Benefits for General Treatment are only payable where the service or item is provided by a Recognised Provider of General Treatment.

E3.6 Westfund may Contract with Recognised Providers of General Treatment. The Benefits that apply within these Contracts may differ from those shown in these rules.

E3.7 Westfund may declare that a provider is no longer a Recognised Provider in the event that the provider fails to adhere to any requirements set down by Westfund.

E3.8 Benefits payable in respect of General Treatment will be the lesser of the:

the actual charge; or

the Benefit payable under these rules for the service or item.

E3.9 Unless Westfund considers there are justifiable circumstances; a Member may only receive Benefits for one service or appliance per day per Recognised Provider. Exceptions to this rule are:

Chiropractic where a Member may receive Benefits for one x-ray and a general consultation per day per Recognised Provider.

Podiatry where a Member may receive Benefits for a diagnostic service (item numbers 101 - 118, 142 - 148) and a general consultation per day per Recognised Provider.

E3.10 Dental Benefits

E3.10.1 Dental Benefits are payable as set out in schedule M1 of these rules and in accordance with the dental item guidelines as maintained by Westfund.

E3.10.2 Where Benefits are available for dental services or appliances, Benefits are only payable when the services or appliances are not considered excessive or unnecessary for the wellbeing of the Member by Westfund’s Dental Expert and where they are primarily non-cosmetic.

E3.10.3 Westfund shall have the right to dispute any claim for Benefits in respect of dental treatment. In the event Westfund disputes a claim for dental treatment, it may appoint a Dental Expert to examine the Member who received the dental treatment and/or any records deemed by the Dental Expert to be relevant to verify the claim. Westfund shall notify the Member in writing of the disputed claim and advise the Member of the Dental Expert appointed. The Dental Expert’s fees shall be paid by Westfund.

E3.10.4 The Dental Expert shall be at liberty, should they think fit, to satisfy himself or herself as to all matters in relation to the claim and provide advice to Westfund. The Member is required to provide to the Dental Expert all documents and records that the Dental Expert may reasonably request in relation to the claim. Westfund shall pay all reasonable expenses of the Member in attending an examination by the Dental Expert. In the event that the Member after being requested by Westfund fails, within a reasonable period of time, to attend the Dental Expert appointed by Westfund or fails or refuses to provide documents or records requested by the Dental Expert, Westfund may refuse payment of Benefits for all dental services associated with the claim.

E3.10.5 No Benefits for Orthodontia are payable until a service has been provided. Where a Member pays in advance of the service, Benefits will be paid progressively against certification of work completed by a Recognised Provider. Benefits will be paid up to the full value of work completed and invoiced within the Benefit limit entitlement (items 825 – 881).

E3.10.6 Benefits for Orthodontia items: Dental Retainers (items 811, 821, 823 and 824) are payable for a maximum of two services per item per Member per Calendar Year. These items are paid at set Item Limits and are not included in the Orthodontia Lifetime Limit.

E3.11 Optical Benefits

E3.11.1 Optical Benefits (other than sunglass Benefit) are only payable for sight correction. This includes Irlen lenses, specially tinted for dyslexia,when provided by a Recognised Provider.

E3.11.2 No Benefits available for tinting, coatings or add-ons.

E3.11.3 A sunglass Benefit is payable for sunglasses purchased through Westfund Care Centres and selected Optical Provider of Choice providers. This Benefit is available only for non-prescription “off the shelf” sunglasses. This Benefit can be used for fit overs.

E3.12 Consultations

E3.12.1 Benefits for all services are only payable for one on one Consultations (in person, video and telecommunication).

Exception to one on one consultations are Antenatal Classes, Exercise Physiology, Physiotherapy, Dietetics/Nutrition, Occupational Therapy, Clinical Psychology, Speech Therapy and Benefits listed under Health Management Programs. These services can be provided in a group setting by a Recognised Provider.

E3.13 Non PBS Pharmaceuticals

E3.13.1 A Pharmaceutical Benefit for a prescription, Vaccination or injection is payable on an item that is prescribed or administered by a medical practitioner. Where the Non PBS Pharmaceutical is provided by a pharmacy the receipt must detail the pharmacy prescription number.

E3.13.2 A Pharmaceutical Benefit is only payable on the amount over the standard Pharmaceutical Benefit Scheme (PBS) co-payment charge. This is re-set each year, effective 1st January.

E3.13.3 Pharmaceutical Benefits for prescriptions, Vaccinations and injections are not payable for:

PBS Items supplied under the PBS scheme

medicinal preparations where not prescribed or administered by a medical practitioner

experimental and clinical trial pharmaceuticals

contraceptives, anabolic steroids or cosmetic injections (e.g. Botox) unless prescribed specifically for the treatment of a medical illness

items which have not been approved for sale in Australia by the authorities that regulate the sale of pharmaceuticals.

E3.14 Health Aids and Appliances

E3.14.1 Refer to Rule G – Claims for the following Benefits require a letter of recommendation or Health Management Declaration Claim Form from a Medicare Registered Practitioner to validate Benefits payable. A letter of recommendation or Health Management Declaration Claim Form is not required when Health Aids and Appliances are provided by or purchased from a Medicare Registered Practitioner.

Documentation is valid for lifetime of Policy:

Artificial Limbs

Compression Garments

Devices for Sleep Apnoea and diagnosed snoring

INR Monitor

Mammary Prostheses and Brassieres (no letter required if a hospitalisation for a mastectomy is on Westfund’s system)

Oximeter

Oxygen and Oxygen Accessories

Repairs to Devices (no letter required if initial purchase is recorded with Westfund)

Respiratory Aids

TENS Machine

Wigs (no letter required if a hospitalisation for a medical condition is on Westfund’s system)

Documentation is valid for 12 months:

Burns Suit

Braces

Low Vision Aids

Mobility Aids

Orthopaedic Boots

Orthotics

E3.14.2 To be eligible for an Orthotic Benefit, orthotic items must be specifically made (custom made) or molded (preformed) for the Member and be for the support, alignment, prevention or correction of deformities of the feet. Benefits for orthotic models/impressions are eligible to be claimed to a maximum of two services per Calendar Year per Member (items 301-305).

E3.14.3 To be eligible for an Orthopaedic Boots Benefit, the orthopaedic boots must be individually handmade (custom made) for the Member and be for the correction of an abnormality.

E3.14.4 To be eligible for a Brace Benefit the brace must contain a solid support stabilizer component.

E3.14.5 To be eligible for a Compression Garment Benefit, the compression garment or anti-embolism garment must be purchased as a consequence of any diagnosed health condition.

E3.14.6 To be eligible for Benefits for repairs to Listed Health Aids and Appliances the claim for the

repairs must be accompanied with a letter of recommendation or Health Management Declaration

Claim Form from a Medicare Registered Practitioner stipulating the need for the device. A letter of

recommendation or Health Management Declaration Claim Form is not required if the device being

repaired has been previously claimed with Westfund. The warranty period for the device must have

lapsed to be eligible for this Benefit.

E3.15 Prevention and Health Management Benefits

E3.15.1 Benefits for membership or class fees with a fitness or aquatic centre are only payable where:

the membership or class is required to enable the Member to undertake a Health Management Program for the treatment of a specific health condition or conditions; and

the Health Management Program has been recommended to the Member by a Medicare Registered Practitioner who is treating the Member for the specific health condition or conditions; and

all documentation required by Westfund has been provided to Westfund; and

the provider must be a Recognised Provider as per Westfund Recognition Criteria.

E3.15.2 Vitamin Benefits are payable for vitamins and minerals listed with Therapeutic Goods

Administration (TGA Approved) and approved by Westfund.

Vitamins and minerals must fulfil the following criteria;

Vitamins must be any vitamin A-Z or Minerals must be iron, potassium, calcium, magnesium or zinc;

Administered orally or intravenously; Intended to aid in a specific vitamin or mineral dietary deficiency; Excludes body building, weight loss, meal replacement or any consumable food or

drink product

E3.15.3 Benefits for Weight Loss Programs are payable only for joining or membership fees.

E3.15.4 For the purpose of chronic disease association fees Benefits, the chronic disease association must be either:

Alzheimer’s Australia

Arthritis Australia

Asthma Foundation

Coeliac Association

Crohn’s and Colitis Australia

Diabetes Australia

Lupus Association of Australia

MedicAlert Foundation

Multiple Sclerosis (MS) Australia

National Association of People with HIV Australia (NAPWHA)

Parkinson’s Australia

Stoma Associations (Ostomy, Colostomy)

E3.15.5 For the purpose of preventative health tests Benefits; the tests must not be Medicare claimable and be one of the following tests:

Bone density test

Bowel testing kit

Calcium score

Mammogram

Mole scan

Thin prep pap test

E3.15.6 For the purpose of ear and eye preventative checks Benefits, the tests must not be Medicare claimable and be one of the following tests:

Audiology Test

Corneal Topography

Optical Coherence Tomography

Retinal Photography

E3.15.7 Omega 3 Benefits are payable for Omega 3 listed with Therapeutic Goods Administration (TGA Approved) and approved by Westfund. Omega 3 must contain the following active ingredients: Omega 3, Fish Oil or Krill Oil.

E3.15.8 Probiotic Benefits are payable for Probiotics listed with Therapeutic Goods Administration (TGA Approved) and approved by Westfund. Probiotics must contain the following active ingredients: Lactobacillus, Bifidobacterium and Streptococcus Thermophiles.

E3.16 Accidental Death Funeral Expenses

E3.16.1 A funeral Benefit of $1,750 per Member is available for Members who held any Policy (excluding Ambulance only cover) prior to 1st April 2007 and have maintained continuous Westfund membership (excluding Ambulance only cover).

Members who have downgraded to Ambulance only cover within this period (1st April 2007 – present) are not eligible for the Benefit.

Members who have terminated their Westfund membership and re-joined the Fund at a later date are not eligible for the Benefit.

Members who were born after 1st April 2007 are not eligible for the Benefit.

E3.17 Laser Eye Surgery Benefit

E3.17.1 For the purpose of Laser Eye Surgery Benefits are payable for Lasik, ASLA and Smile procedures and must be performed by a Medicare registered Ophthalmologist.

E3.18 Outpatient Travel Benefit

E3.18.1 An Outpatient Travel Benefit is payable for travel expenses incurred by a Member to attend outpatient medical specialist services when referred by a Medicare Registered Practitioner. The provider must be a recognised specialist as per Westfund’s Recognition Criteria.

E3.18.2 An Outpatient Travel Benefit will only be paid for medical specialist services where:

in the case of an outpatient service, a Medicare item number is billed for that service;

in the case of a Specialist Dentist, a dental consultation item number is billed for that service;

E3.18.3 Where a Member is not billed for a medical service (e.g. post-operative consultation), a letter of attendance from the medical specialist is required.

E3.18.4 Benefits will be paid on a grouped kilometre basis, in excess of 150 kilometres round trip from the Member’s home locality to the locality of the consultation. This Benefit is limited to one service per Member per day.

E3.18.5 The following limits apply to Benefits for outpatient travel expenses:

Distance Travelled Benefit

0-149km Nil

150km-200km $20

201km-250km $25

251km-300km $30

301km-350km $40

351km-400km $50

401km-450km $60

451km+ $70

E4 Other

F LIMITATION OF BENEFITS

F1 Co Payments F1.1 A Co-Payment may be required under particular Policies where detailed in Schedules J-L.

F1.2 A Co-Payment may also be required where the Member has transferred from a Policy with the

health benefits fund of another private health insurer that applies Co-Payments and a Waiting Period

still applies to his or her Policy.

F2 Excesses F2.1 An Excess may be required under particular Policies where detailed in Schedules I-L.

F2.2 An Excess may also be required where the Member has Transferred from a Policy with the

health benefits fund of another private health insurer that applies Excesses and a Waiting Period

still applies to his or her Policy.

F2.3 If the Hospital admission fee is less than the Excess payable on the Policy for a Member for

their first admission, the balance of the Excess shall be applied to any subsequent admissions within

the same Calendar Year; up to the value of their Excess.

F3 Waiting Periods F3.1 Benefits are not payable in respect of services provided to a Member during a Waiting Period.

F3.2 When a Member of the health benefits Fund of another private health insurer Transfers to

Westfund without a break in coverage, Westfund may apply all relevant Waiting Periods:

to any Benefits under the Westfund Policy that were not provided under the previous cover;

to any difference between the benefits that would have been provided under the previous cover and the Benefits payable by Westfund where the Westfund Policy Benefit is higher;

to the unexpired portions of any Waiting Periods not fully served under the previous cover.

to the difference between any Excess or Co-Payment payable under the previous policy and the new Policy (where the previous policy carried a higher Excess or Co-Payment).

F3.3 Where a Westfund Member Transfers to another Westfund Policy he or she shall be treated as a Transfer from the health benefits fund of another private health insurer in relation to the application of Waiting Periods.

F3.4 A newborn Child of a Member will be covered if they have been added to an eligible Policy (refer

rule C1.3) within three months of birth.

F3.5 Waiting Periods do not apply to a newborn Child of a Member that has served all Waiting

Periods. Any Waiting Periods that remain for a Member at the time of birth will apply to a newborn

Child. A Child added to a Policy three months after their birth date will be subject to all Waiting

Periods.

F3.6 A Waiting Period will not apply to a Policy that covers a person who held a gold card or was

entitled to treatment under a gold card (as defined in the PHI Act) or to members of the Australian

Defence Force or people in Antarctica who have health cover provided as part of their employment.

F3.7 Benefits are not payable in respect of services provided during a Waiting Period.

The following Waiting Periods apply to Benefits payable for Hospital Treatment:

Accident-related hospitalisation 1 day

Hospital psychiatric services, Palliative care and Rehabilitation 2 months

Pregnancy and birth 12 months

Treatment of a Pre-existing Condition

(excluding Hospital psychiatric services, Palliative care and Rehabilitation)

12 months

All other treatments (not listed above) 2 months

Accommodation Benefit, Inpatient Travel Benefit 12 months

Chronic Disease Management Programs 12 months

The following Waiting Periods apply to Benefits payable for General Treatment:

Emergency Ambulance Transport 1 day

Non-Emergency Patient Transport, General Dental, Optical, Chiropractic,

Osteopathic, Physiotherapy, Exercise Physiology, Complementary

Therapies, Prescriptions, Vaccinations, Injections, Prevention and Health

Management (excluding antenatal classes), Sunglasses

2 months

Major Dental, Orthodontia, Dental Top Up, Surgical Treatment by a

Podiatrist, Antenatal Classes, Health Aids and Appliances (excluding

Hearing Aids), Outpatient Travel Benefit

12 months

Hearing Aids, Laser Eye Surgery 36 months

F3.8 A Member who has held a Policy with Hospital cover for at least 2 months and upgrades to a

Policy which includes psychiatric treatment may elect to waive the 2 month Waiting Period that

applies to psychiatric treatment upon upgrade. This waiver can only be accessed once in a Member's

lifetime; as specified in the Private Health Insurance (Complying Product) Amendment (Psychiatric

Care) Rules 2018.

F4 Exclusions F4.1 Some procedures may be excluded under particular Policies where detailed in Schedules I-L of

these rules.

F5 Restricted Benefits F5.1 Restricted Benefits may apply under particular Policies where detailed in Schedules I-L.

F6 Compensation Damages and Provisional Payment of Claims F6.1 The following conditions apply to Benefits in respect of compensable services:

Benefits are not payable in respect of services provided to a Member as a result of an Accident, illness, injury, condition or other incident for which there exists in the opinion of

Westfund, a right to claim compensation from a third party or authority at law or under any insurance or scheme of arrangement or for which the Member has personally received a payment or consideration in settlement of a claim for compensation or damages however the settlement is described, including payments by way of ex gratia and/or non-disclosed settlement.

In circumstances in which the preceding paragraph applies, and Westfund makes an ex gratia payment, the Member shall repay to Westfund any such ex gratia payment, and interest at no more than the Commonwealth Bank’s 90 day bill rate at the relevant time, where the Member subsequently becomes entitled to receive a payment or consideration in settlement of a claim for compensation or damages (howsoever described). The liability of the Member to repay shall apply regardless of whether the Member continues to be a Member of Westfund.

Where the Member receives, or becomes entitled to receive, a lesser amount than the sum of ex gratia payments made by Westfund, then the Member’s liability to repay to Westfund shall be limited to such lesser amount.

In addition to any other terms or conditions which Westfund may apply under this rule, the Member shall provide:

an undertaking in a form approved by Westfund to repay to Westfund the amount of the ex gratia payment;

an undertaking to keep Westfund informed of progress towards resolution of the claim and to provide Westfund with full particulars of the settlement terms reached; and

an undertaking to notify Westfund within 14 days either personally or through the Member’s solicitor when a settlement is reached.

F7 Other

G CLAIMS

G1 General G1.1 Claims shall be submitted to Westfund on the required form either by mail, in person to a

Westfund Care Centre, via fax or email. A claim may also be submitted via the Westfund website

(www.westfund.com.au) or via the Westfund App.

G1.2 Claim forms, where required, must be completed in full including declarations by Member in

relation to third party and workers compensation claims.

G1.3 Westfund reserves the right to refuse a claim that is not submitted on the correct form.

G1.4 Documentation required in support of a Benefit claim is detailed below:

Claim Type Claim Form and Account Supplementary Information or

Documentation Required

Medical (non-Access

Gap)

Standard Claim Form plus

Medicare Account/Receipt

Nil

Dental

General Dental

Major Dental

Standard Claim Form plus

Account/Receipt

Nil

Dental

Orthodontia

Standard Claim Form plus

Account/Receipt

Prior to first claim a treatment

plan must be submitted

Certification of work completed

for progress payments

Optical Standard Claim Form plus

Account/Receipt

Nil

Chiropractic and

Osteopathy

Standard Claim Form plus

Account/Receipt

Nil

Physiotherapy and

Exercise Physiology

Standard Claim Form plus

Account/Receipt

Nil

Complementary

Therapies

Acupuncture

Chinese Herbalism

Clinical Psychology

Dietetic

Home Nursing

Myotherapy

Nutrition

Occupational Therapy

Podiatry

Remedial Massage

Speech Therapy

Vision (Eye) Therapy

Standard Claim Form plus

Account/Receipt

Nil

Non PBS

Pharmaceuticals /

Vaccinations /

Injections

Standard Claim Form plus

Account/Receipt

Official Pharmacy Receipt

required where provided by

pharmacy

Contraceptives, anabolic steroids

or cosmetic injections must be

accompanied with a letter by the

prescribing Medicare Registered

Practitioner detailing that the

pharmaceutical is treating a

specific health condition. (Letter

is valid for 12 months)

Prevention and Health

Management

Aquatic Programs

Fitness Centre

Standard Claim Form or Health

Management Declaration Claim

Form plus Account/Receipt

Letter of recommendation or

Health Management Declaration

Claim Form must be completed

by a Medicare Registered

Virtual Gastric Banding

Weight Loss Programs

Practitioner and detail the

specific health condition being

treated

Prevention and Health

Management

Antenatal Classes

Audiology Test

Bone Density Tests

Bowel Testing Kits

Calcium Score

Chronic Disease Association Fees

Corneal Topography

Diabetes Education

Mammograms

Mole Scanning

Omega 3

Optical Coherence Tomography

Probiotics

Quit Smoking Programs

Retinal Photography

Thin Prep Pap Tests

Vitamins

Standard Claim Form plus

Account/Receipt

Nil

Health Aids and

Appliances

Artificial Limbs

Braces

Burns Suit

Compression Garments

Devices for Sleep Apnoea and diagnosed snoring

INR Monitor

Low Vision Aids

Mammary Prostheses and brassieres

Mobility Aids

Orthopaedic Boots (custom made)

Orthotics (custom made/preformed)

Oximeter

Oxygen and Accessories

Standard Claim Form or Health

Management Declaration Claim

Form plus Account/Receipt

or:

Standard Claim Form plus

Account/Receipt if Health Aid or

Appliance is provided by or

purchased/hired from a Medicare

Registered Practitioner.

Letter of recommendation or

Health Management Declaration

Claim Form must be provided by

a Medicare Registered

Practitioner and detail the need

for the appliance to treat the

specific health condition.

Lifetime Documentation

Required:

Artificial Limbs

Compression Garments

Devices for Sleep Apnoea and diagnosed snoring

INR Monitor

Mammary Prostheses and Brassieres (no letter required if a hospitalisation for a mastectomy is recorded with Westfund)

Oximeter

Oxygen and Oxygen Accessories

Repairs to Devices

Respiratory Aids

TENS Machine

Wigs

Respiratory Aids

Repairs to Devices (unless initial purchase is recorded with Westfund)

TENS Machine

Wigs (no letter required if a hospitalisation for a medical condition is recorded with Westfund)

Documentation Required every

12 months:

Burns Suit

Braces

Orthopaedic Boots

Orthotics

Low Vision Aids

Mobility Aids

Health Aids and

Appliances

Blood Glucose Monitors

Blood Pressure Monitors

CPAP Accessories

CPAP Masks

Hearing Aids and FM Systems

TENS Accessories

Standard Claim Form plus

Account/Receipt

Nil

Ambulance

Emergency Ambulance Transport

Non-Emergency Patient Transport

Standard Claim Form plus

Account/Receipt

Nil

Funeral Expenses Standard Claim Form plus Funeral

Account/Receipt

Confirmation of date of death is

required (refer rule C8.10)

Accommodation Travel & Accommodation Claim

Form plus Hotel/Motel Receipt

Record of hospitalisation on

membership

Inpatient Travel Travel & Accommodation Claim

Form

Record of hospitalisation on

membership

Outpatient Travel Travel & Accommodation Claim

Form

Receipt or letter of attendance

from specialist

G1.5 Westfund will accept a photocopy, faxed or emailed copy of any account or receipt. In the case

of photocopied, faxed and emailed accounts/receipts, original documents must be retained by the

Member for a minimum of 24 months from the date the claim is made. Westfund may request to

sight the original document during this time and may seek to recover Benefits paid where this cannot

be produced.

G1.6 Westfund will not accept any account, receipt, prescription or any other document which has

been altered in any way by any person so as to misrepresent any of the original details contained on

those documents.

G1.7 Accounts or receipts issued by providers must contain the following information to permit

payment of a Benefit:

The name and provider number of the issuing provider

The date of issue of the invoice

The name of the patient

Date of service and type of service

Cost of service or services should be shown as individual amounts (except in dental as these may be bulked as a total amount)

Any amount paid to the provider and date paid including any discounts given

Any amount outstanding

Any notations such as ‘Quote’ or ‘Duplicate’ where necessary.

Additional Information required for Dental and Optical Receipts:

Dental/Optical Item Numbers

Additional Information required for Prescriptions/Vaccinations/Injections where official pharmacy

receipt is provided:

Private/Non NHS/Non PBS

Script number

Prescriber Name(doctor)

Prescriber Number

G1.8 Benefits are not payable if an application or claim form contains false or misleading information.

G1.9 All documents submitted in connection with a claim become the property of Westfund, unless

otherwise agreed.

G1.10 Westfund reserves the right to request further information including a copy of any treatment

plans.

G1.11 Benefits are not payable where a claim is lodged more than two (2) years after the date of

service. Westfund may waive this rule at its discretion.

G1.12 Benefits paid by cheque are only payable to the Provider or the Primary Member unless the

Primary Member requests otherwise.

G1.13 Benefits paid by cash are payable to either the Primary Member or his or her authorised agent.

G1.14 Any supplementary documentation required from a Medicare Registered Practitioner as noted

in G1.4 must be less than 12 months old at the date the service was provided.

G2 Other G2.1 Westfund may require certain claims to be submitted on or accompanied by specific forms

depending on the nature or circumstances of the service including but not limited to WorkCover, acute

care, intensive care and specific services in contracted Hospitals.